A CASE OF CHRONIC ALCHOHOLIC LIVER DISEASE PRESENTED IN SUMMER 2023
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I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom.
A 43 year old male , petrol pump supervisor by profession came to the opd with chief complaints of shortness of breath and abdominal bloating .
Date of admission: 20/06/23
CHIEF COMPLAINTS
➤ Shortness of breath since 15 days
➤ Abdominal bloating since 15 days
➤ Vomitting since 3 days .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15 days back. Then he developed abdominal bloating and discomfort which was aggravated by taking food .
Not associated with belching , regurgitation
He visited local hospital in Nalgonda where he was diagnosed with Jaundice and Liver infection . He didn't get admitted in the hospital due to economic issues and came to our hospital.
Not associated with belching , regurgitation.
He also developed c/o shortness of breath after taking food and on doing ordinary work (Grade III) .
No c/o orthopnea , PND , chest pain , decreased urine output.
He had 4-5 episodes of vomitting , which was watery , non bilious, non projectile, not blood stained .
No c/o fever , cough , cold .
PAST HISTORY
➤ k/c/o hypertension and diabetes mellitus since 2-3 years and on medication
➤ Not a k/c/o TB, epilepsy , asthma ,CAD , thyroid disorders , CVA.
➤ No history of blood transfusion.
➤ He had h/o femur fracture for which he had surgery .
PERSONAL HISTORY
➤Occupation: Petrol pump supervisor
➤Patient is married .
➤Patient takes a mixed diet and has normal appetite.
➤Sleep : Regular
➤Bowel movements are regular , micturition normal .
➤No known allergies .
➤ Addictions - drinks alcohol daily 90ml since 5 yrs .
Last binge 15 days ago .
FAMILY HISTORY
Not significant .
GENERAL EXAMINATION
Patient is conscious,coherent , non-cooperative , well known with time, place, person
He is well built and moderately nourished.
➤Pallor : not seen
➤Icterus : seen
➤Cyanosis : not seen
➤Clubbing : not seen
➤Lymphadenopathy : not seen
➤Edema : not seen .
VITALS
➤ Temperature : 99.7℉
➤PR : 78 beats per minute
➤BP : 110/80 mm Hg
➤RR : 14 cycles per minute
➤SpO2 : 94% in room air
➤ GRBS : 189 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
➤ Breath sounds - vesicular
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Distended .
➤Equal movements in all the quadrants.
➤No visible pulsation and
localized swellings , hernial orifices intact .
➤Umbilicus:inverted
➤Skin over the abdomen is shiny
➤Visible superficial abdominal vein running vertically down is seen
PALPATION
➤Liver , spleen not palpable.
➤ No tenderness .
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
➤No signs of meningeal irritation
PROVISIONAL DIAGNOSIS: CHRONIC ALCHOHOLIC LIVER DISEASE .
INVESTIGATIONS
1. ECG
Dt : 21/06/23
2. USG
Dt : 21/06/23
TREATMENT
1. Tab. Pan 40mg PO/OD 7am
2. Tab. Udiliv 300mg PO/BD
3. Syp Hepamer 15ml PO/TID
4. Syp Lactulose PO/OD 9pm
5. Tab. Glimi-MI PO/OD 8am
6. Tab. Amlodine 5MU PO/OD 8am
